MPS cases. The danger of the casual aside Mr J, a 28-year-old teacher, called his local OOH service...

MPS cases

The danger of the casual aside

Mr J, a 28-year-old teacher, called his local OOH service one evening complaining of vomiting and diarrhoea, some abdominal pain and dysuria.

He had just returned from the cinema with his wife and the symptoms had come on during the film.

No relevant PMHx and no other meds. Vomiting was getting worse and he was unable to

attend the centre, so a visit was arranged and Dr A called to see him at home that night.

The danger of the casual aside

Dr A examined him. Mr J was afebrile, had a soft abdomen with

suprapubic tenderness but no signs of guarding or rebound.

Urine dip - 2+ leucs + protein Provisional Dx of UTI. Prescribed course of ABx with simple analgesia,

recommending that Mr J should see his own GP if things did not improve.

No record of time frame for this.

Happy with Mx so far?

The danger of the casual aside Mr J’s own GP, Dr C, was in the middle of a

busy afternoon surgery 2 days later. Mr J’s wife was attending a routine appointment

with him to get a repeat prescription for OCP + Ax of chronic eczema.

No mention of her husband’s problems until the end of the consultation, when she stood up and handed over the record of Mr J’s OOH contact.

The danger of the casual aside

At this point Mrs J claimed that she informed Dr C that her husband still did not feel any better and in fact she was now frightened that he might have appendicitis.

She reports that during the exchange that followed Dr C advised her to “give the tablets time to work”.

Dr C, however, made no record of this conversation and had no memory of Mrs J giving such detailed information, or indeed that she was so concerned about her husband’s condition.

What would you have done?

The danger of the casual aside

Mr J’s pain and general symptoms persisted. He did not try to contact Dr C or his own surgery during this time, but 2 days later he contacted the OOH service once again, requesting a home visit.

A different doctor assessed him and, based on his findings and the history, made a diagnosis of perforated appendicitis and peritonitis, admitting him to hospital as an emergency.

Mr J subsequently lodged a claim against Dr C.

Learning points?

Expert opinion No record made of the conversation between Dr C

and Mrs J at the surgery. Expert GP opinion advised that if Mrs J had

mentioned she thought her husband may be suffering from appendicitis, Dr C should at least have obtained further info about the case + offered a consultation on that day.

However, as Dr C recalled the conversation with Mrs J as a brief mention on her departure about an OOH visit with no specific voicing of her concerns, or that her husband was still unwell, the experts thought his actions were reasonable.

Outcome

MPS defended the case to trial. The court found in favour of Mr J and awarded moderate damages.

Learning points The “casual aside”, often thrown in at the end of a

consultation and not always at a convenient moment, has the potential to cause problems.

An exhaustive history is not expected, but safety-netting is essential and should help to protect the patient and the doctor involved.

When a patient mentions a medical problem to you, you have a duty to deal with it, but not necessarily there and then.

Learning points A short note of Mrs J's comment might well have

resolved this issue more quickly. Relying on one's recollection is often hazardous. Courts have to resolve a conflict of evidence and

may prefer the recollection of a patient, for whom this was a unique experience, to that of a doctor, for whom this was one in a series of consultations.

The courts make no allowances for the circumstances of a consultation, eg, in this case, where the surgery was very busy.

Wrongly Reassured

Wrongly reassured

Miss R, 28yrs, stable relationship. Worked shifts in a call centre, forgetting to take OCP.

Tried IUCD in the past, developed an infection, had to be removed, not keen on trying again.

After discussing potential options with her GP, Dr F, decided she would like to try depot.

As part of the consultation and counselling, she was warned that she could expect some changes to her vaginal bleeding pattern, particularly during the first injection cycle.

Happy with Mx so far?

Wrongly reassured

Attending for 3rd injection, 6m later, she told the nurse she was getting light PV bleeding at times.

It didn’t cause her distress and she enjoyed the freedom that the injection gave her, particularly with her irregular hours, she didn’t have to worry about setting her alarm to take the pill.

The nurse reassured Miss R, told her that some light bleeding was common with the injections.

There was no record made of the need for any further medical review if the bleeding did not stop.

And now?

Wrongly reassured

Over the next 18 months, Miss R made several mentions to nursing and medical staff that she was still having irregular PV bleeding.

There were brief records made of 3 such discussions. 2 involved discussions between nurse + duty doctor at the surgery, at no point was a pelvic examination undertaken, or any more detailed gynae Hx recorded.

One entry implied that previous records had not been looked at by the doctor involved.

How about now?

Wrongly reassured

Miss R continued with the depot Nearly 2yrs after the first one, she made an

appointment with Dr F. The irregular bleeding had never stopped and,

although it had originally only been 3 or 4 times a month, now it was on an almost daily basis.

Dr F made an appointment for Miss R to have a cervical smear.

Wrongly reassured

The smear showed severely dyskaryotic cells and she was referred urgently to gynaecology.

Miss R had an invasive cervical carcinoma and a radical hysterectomy was carried out.

Outcome

A claim was made and expert opinion found the case to be indefensible.

She successfully sued the practice for a high sum.

Learning Points

Learning points

Clinicians managing women with any unusual bleeding pattern, especially while using progesterone-only injectable (POI) contraceptives, should take a full history and conduct an appropriate gynaecological examination.

While spotting and mild PV bleeding is common in the 1st cycle of POI, if this becomes persistent, or the bleeding occurs after a period of amenorrhoea, then exclude gynae problems that are clinically indicated.

Learning points

If the medical notes are available to the clinician and they are not reviewed for an ongoing problem, it is very difficult to defend a claim or complaint. 

Having a look at a patient’s previous attendances can give invaluable clues to diagnosing a new problem. 

It is important to listen carefully to patients’ concerns, especially symptoms mentioned as a “by the way” comment. 

Learning points

As care is often team-based, involving GPs, nurses, nurse practitioners, it is essential to have a protocol in place where anything untoward is flagged. 

Remember the red flags for referral for gynaecological cancers:

Remember red flags for referral for gynae cancers:

Consider urgent referral for persistent IMB/PCB with a normal pelvic examination. 

If lesions suspicious of cervical/vaginal Ca seen on speculum, smear result is not needed before referral and a previous negative smear test is not a reason to delay referral (NICE guidelines).

The 1st symptoms of gynae Ca may be alterations in menstrual cycle, IMB, PCB, PMB, or vaginal discharge.

If a pt reports any of these symptoms, the doctor should undertake a full pelvic examination, including speculum examination of the cervix.